RN Nursing · Normal Postpartum Care · Practice question
A nurse is collecting data from a client who is 14 hr postpartum. The nurse notes: breasts soft; fundus firm, slightly deviated to the right; moderate lochia rubra; temperature 37.7° C (100° F), pulse rate 88/min, respiratory rate 18/min. Which of the following actions should the nurse perform?
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Report the client's temperature elevation.
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Increase IV fluids.
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Encourage the client to nurse more frequently so her milk will come in.
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✓
Ask the client to empty her bladder.
Answer & explanation
Correct: Ask the client to empty her bladder.
The fundus that is slightly deviated to the right at 14 hours postpartum strongly suggests a full bladder, because a distended bladder displaces the uterus from the midline and prevents it from contracting firmly, which increases hemorrhage risk. The priority nursing action is to ask the client to empty her bladder, which should return the fundus to midline and maintain uterine tone. The temperature of 37.7° C (100° F) at 14 hours postpartum is within normal limits for the first 24 hours following delivery due to the physiological stress of labor; it does not require reporting at this stage. Increasing IV fluids is not indicated by the data provided and would not address the underlying cause of the deviated fundus. Encouraging more frequent nursing to stimulate milk let-down is not relevant to the current priority finding of uterine displacement; the breasts are described as soft and appropriate for early postpartum. Addressing bladder distension first directly corrects both the fundal deviation and the risk of atony, making it the correct priority action.
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